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STATE OF CALIFORNIA WATER RESOURCES CONTRO90ARD FORM `A': UNDERGROUND STORAGE TANK PROGRAM SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION COMPLETE THIS FORM FOR EACH FACILITY/SITE IHARK ONLY F-1 I NEW PERMIT [—] 3 RENEWAL PERMIT ONE ITEM F-1 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT m 6 TEMPORARY,!rCHANGE OF SITE CLOSURE P� {JT CLOS D SITE I I. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) FACILITY/SITE NAME �_ CARE OF ADDRESS INFORMATION CARE OF ADDRESS INFORMATION # of TANKS a ITE I I � I Z I)l ❑ CORPORATION ❑ LOCAL -AGENCY Cl FEDERAL -AGENCY ❑ INDIVIDUAL ❑ COUNTY -AGENCY CITY NAME STATE ADDRESS PHONE If. WITH AREA CODE I NEAREST CROSS STREET ✓ Boz to Wicale ❑ PARTNERSHIP ❑ STATE -AGENCY CENSUS TRA T # 71 O SUPERVISOR -DISTRICT C DE � BUSINESS PLAN FILED YES ❑ NO ❑ CORPORATION ❑ LOCAL -AGENCY Cl FEDERAL -AGENCY CHECK # PERMIT AMOUNT (/// FEE CODE ❑ INDIVIDUAL ❑ COUNTY -AGENCY CITY NAME BYN� j STATE ZIP CODE SITE PHONE It. WITH AREA C (/ CA TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR ❑ 4 PROCESSOR ✓ Box it INDIAN EPA ID N 1 GAS STATION 3 FARM ❑❑ ❑ 5 OTHER TRUST LANDS or ❑ # of TAN / AT THIS ITE EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY) DAYS: NAME (LAST, FIRST) PHONE N WITH AREA CODE DAYS: NAME (LAST, FIRST) PHONE N W117rXREA CODE NIGHTS: NAME (LAST, FIRST) PHONE # WITH AREA CODE NIGHTS: NAME (LAST, FIRST) PHONE # WITH AREA CODE II. PROPERTY OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓ Box to indicate ❑ PARTNERSHIP ❑ STATE -AGENCY # of TANKS a ITE I I � I Z I)l ❑ CORPORATION ❑ LOCAL -AGENCY Cl FEDERAL -AGENCY ❑ INDIVIDUAL ❑ COUNTY -AGENCY CITY NAME STATE ZIP CODE PHONE If. WITH AREA CODE III. TANK OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓ Box to indicate ❑ PARTNERSHIP ❑ STATE -AGENCY # of TANKS a ITE I I � I Z I)l ❑ CORPORATION ❑ LOCAL -AGENCY ❑ FEDERAL -AGENCY ❑ INDIVIDUAL ❑ COUNTY -AGENCY CITY NAME STATE ZIP CODE PHONE #, WITH AREA CODE IV. LEGAL NOTIFICATION AND BILLING ADDRESS CHECK ONE (1) BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. ❑ II. ❑ III. ❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY, AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. APPLICANT'S NAME (PRINTED & SIGNATURE) DATE LOCAL AGENCY USE ONLY [MCOUNTY# JURISDICTION # I I AGENCY# I FACILITY ID # I 111-7 13 12-4- F # of TANKS a ITE I I � I Z I)l CURRENT LOCAL AGENC FAC LI ID # APPROVED BY NAME PHONE # WITH AR CODE PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCATI OE CENSUS TRA T # 71 O SUPERVISOR -DISTRICT C DE � BUSINESS PLAN FILED YES ❑ NO DATE FILED CHECK # PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT N BYN� THIS FORM MUST BE ACCOMPANIED BY AT LEAST (1) OR MORE TANK PERMIT FORM 'B' APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY Q � � FORM A (3-2-88) �`� DATA PROCESSING COPY z 10 I� —4 CD C)